User involvement in health and social care in Northern Ireland

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1 STAKEHOLDER PARTICIPATION REPORT 18 Looking out from the middle: User involvement in health and social care in Northern Ireland

2 STAKEHOLDER STAKEHOLDER PARTICIPATION PARTICIPATION REPORT 18 Looking out from the middle: user involvement in health and social care in Northern Ireland We need to see what we are being consulted about is making a difference we have to be in the middle looking out. (service user) Users of services are in the best position to highlight what is good and poor about the services they receive. (senior manager) Joe Duffy

3 First published in Great Britain in February 2008 by the Social Care Institute for Excellence SCIE 2008 All rights reserved Written by Joe Duffy This report is available in print and online Social Care Institute for Excellence Goldings House 2 Hay s Lane London SE1 2HB tel fax textphone Front cover photograph kindly supplied by Photofusion, ii Looking out from the middle

4 STAKEHOLDER PARTICIPATION Contents Acknowledgements Summary Recommendations v vi x 1 Introduction The commissioning organisations Aims of the consultation 1 2 Methodology: how the consultation was carried out Introduction Managing the project Reviewing the literature Designing a sample frame for the consultation Selecting the sample Ethical approval Designing the interview Preparation for the interviews Conducting the interviews Scoping user involvement: the current situation 6 in Northern Ireland 2.11 Analysing the findings from the consultation Discussion of themes and forming 8 recommendations 2.13 Limitations of the methodology 8 3 History and principles of user involvement Introduction overview of national and local legislation and 11 policy on service user involvement 3.3 User participation: what does it mean? Challenges and opportunities for developing 12 service user involvement in Northern Ireland 3.5 Beyond tokenism: mainstreaming service user 12 involvement The way forward 13 4 The current situation in Northern Ireland Introduction Northern Health and Social Services Board Western Health and Social Services Board Eastern Health and Social Services Board Southern Health and Social Services Board Service user involvement in the voluntary sector 16 iii

5 5 Numbers of service user organisations in 18 Northern Ireland 6 Findings Analysis of the themes Theme 1: Communication Organisations communicating with 19 service users and carers Skills needed by users Organisations communicating 21 with the public Possible barriers/obstacles to 22 effective communication 6.3 Theme 2: Values Theme 3: Training Theme 4: Practicalities theme 5: Knowledge of organisations Theme 6: Support for a user group network Theme 7: Feedback and outcomes Theme 8: Resources User groups consulted: important messages 31 7 Conclusion 33 Appendix 1: User involvement definitions 34 Appendix 2: Groups participating in the consultation 35 Appendix 3: Interview schedule 36 Appendix 4: Policy and legislative themes on user 41 involvement: Northern Ireland and United Kingdom References 44 iv Looking out from the middle

6 Acknowledgements I am grateful to the following groups and individuals for their contributions to this consultation: The Social Care Institute for Excellence (SCIE), the Northern Ireland Social Care Council (NISCC) and the Regulation and Quality Improvement Authority (RQIA) for funding the project. The project steering group, Carers and Users Support Enterprise (CAUSE), Voice of Young People in Care (VOYPIC) and the A Team (an advocacy group of adults with learning disabilities based in Laurel s Day Centre, Newry County Down, who work together to improve the service that they receive). The commissioners reference group (Brendan Johnston, Chief Executive, NISCC; Teresa Nixon, Director of Operations and Chief Adviser of Social Work, RQIA; Pete Fleischmann, Principal Adviser Participation, SCIE; Margaret Shevlin, NISCC user and carer reference group). Pete Fleischmann for project management. All of the groups listed in Appendix 2 and staff members in the statutory, voluntary and private sectors who agreed to provide information for the consultation. I am also grateful to the members of the project/research team who were allocated responsibility for specific parts of the project: A Team members, for interview completion and summaries. Dr Berni Kelly, for research design and report peer review. Mr Brendan McKeever (Family Information Group), for assisting with the development of case studies, proof reading the report, interview design, interview completion, results analysis and developing the service user database. Mr Damien Kavanagh, carer advocate, for compiling the database of service user groups and construction of the spreadsheet. Mr George Wilson, Lorna Conn and Joe Duffy, for writing the history and principles of user involvement section, interview completion and summaries. Dr Jim Campbell, for overall research design, results analysis, report proofing and advice on methodological issues. Dr John Devaney, for interview completion and summaries and report proofing. The Lobbying Activism and Research Group members (LARG), for interview design, interview completion and summaries, report proof reading, results analysis and developing the service user database. Dr Stan Houston, for interview completion and summaries. v Looking out from the middle

7 STAKEHOLDER PARTICIPATION Summary Project aims Looking across health and social care services for children, young people and adults the project had four aims: 1. To provide a short summary of the history and principles of user involvement. 2. To describe the current situation in Northern Ireland. 3. To discuss a range of options for the further inclusion and participation of users in the work of NISCC, RQIA and SCIE. 4. To make recommendations to inform the development of a future strategy for user involvement at a strategic level in Northern Ireland. Method: how the team did the work The team combined desk research (reading and thinking about user involvement) and interviews (speaking to people about user involvement). A total of 148 people were interviewed. All this information was collected together and analysed by the team. A very broad range of service user and carer groups, organisations representing user interests and stakeholders with responsibility for service delivery in the health and social care sectors in Northern Ireland were interviewed. It was important that minority ethnic and hard-to-reach/seldom heard groups perspectives were covered. In addition consideration was given to the 1998 Northern Ireland Act (Section 75). Findings: what the team found out The findings from this consultation are presented as themes that commonly occurred in the interviews. The following table lists the themes and shows how many times they were mentioned in the interviews. Theme Frequency in interviews 1. Communication Values Training Practicalities Knowledge of organisations Support for a user group network Feedback and Outcomes Resources 13 vi

8 Themes in brief The content of each theme is outlined below. The text is supplemented with quotes from interviewees. 1. Communication Good communication skills is a must, training should be mandatory for all staff as good communication does not happen by chance, we all have to work at it. (Residential Unit for Older People) Respondents discussed communication in terms of the way organisations seeking user involvement communicate in a broad sense with the general public and structure their own working practices. This theme includes references to the skills and sensitivities which organisations need to take on board to ensure that all aspects of their business are accessible to service users and carers. The consultation concluded that different user groups require different approaches to involvement. 2. Values It is a basic right of all human beings to have a say in any decision making that is going to affect their well-being/care or life in any way. (Residential Unit for Older People) Effective user involvement and partnership working must be based on values such as respect, humanity, partnership, inclusion and a commitment to respecting the right to consultation and involvement. To be truly effective these values must be intergral to the way the three organisations engage users. 3. Training Anyone involved in a working organisation should have a detailed knowledge of that organisation... this can be obtained by induction courses into the organisation. (Carers Group) Training is important for everybody engaged in the process of user involvement. Although some users already felt well skilled in certain areas, many respondents felt that this should be a continuous process, important for both users as individuals wanting to build their own capacity and for staff in organisations. 4. Practicalities Organisations need to build relationships and allow trust to develop. (Youth Justice Group) User participation must be supported by keeping the emphasis on the practical considerations which help in making this work. Many examples of these were provided such as payments, timing of meetings, conduct of meetings, use of language, evaluation of user contributions, childcare and/or carer support and additional support before, during and after meetings. vii Looking out from the middle

9 STAKEHOLDER PARTICIPATION 5. Knowledge of Organisations Users of services are in the best position to highlight what is good and poor about the services they receive... they also provide a unique insight into how services can be redesigned or improved. (senior manager) A recurrent theme from the many interviews was the fact that respondents knew very little about the work of NISCC, RQIA and SCIE. Nevertheless, what is encouraging was the willingness of groups and individuals to become fully involved in the work of such organisations, once they began to understand what they were about and who they were. 6. Support for a user group network When posed with a question about the development of a national user network, most respondents felt that this was a good idea. A number of concerns were raised about how this would realistically work. Critically it was the ownership of any network, by users themselves, which was highlighted on a number of occasions. The chart below shows respondents thoughts on how useful a Northern Ireland Network would be in terms of advancing issues around user involvement. Development of a network 6 Very useful Of some use No use at all Feedback and outcomes Organisations need to provide feedback about how the views of service users have brought about changes. (Mental Health Support/Women s Health Group) A constant theme in the responses was the need for organisations to give feedback to individuals and groups with whom they have consulted as a real way of avoiding both tokenism and consultation fatigue. This emerged as a key theme that had to be addressed, to ensure that negative experiences were overcome and future engagement assured. 8. Resources Larger organisations must invest in participation work, speak to experts, get guidance and share good practice. (Young People s Support Group) This theme recognises that extra resources need to be committed by agencies to effectively support user involvement. In some cases this could mean having a designated staff member identified as a link person and having a budget associated with user engagement. viii

10 Recommendations These recommendations are based on the findings from four different parts of this consultation. They therefore link directly to: the key messages from the literature on user involvement; the findings and themes from the interviews with all of the various stakeholders; examples of good practice emerging from the user groups and organisations consulted; examples of good practice evidenced from different parts of the statutory, private and voluntary sectors in Northern Ireland. The recommendations are described and then followed up with further information that gives examples of how the recommendation can be followed through. Each recommendation presented will also be linked in with the particular theme that it is associated with in terms of its relationship to the consultation findings. Recommendation 1 The three commissioning organisations should consider developing a participation group involving their participation staff and a cross-section of user groups. This group should focus on core aspects of each of the organisation s activities around user involvement. Themes: Communication, Values, Training, Feedback and outcomes, Knowledge of organisations Proposed actions for development This group would support each organisation s work on user involvement. It could, for example, have a role in giving feedback on the written publications of each organisation, share examples of good practice in each organisation, develop evaluation and checklist tools, develop a certificated training programme around user involvement and plan communication strategies for each organisation including planning an annual information event. The membership of this group should be reviewed annually to ensure the continuing representativeness of a variety of user perspectives. This group should provide an annual report to the three chief executives of the sponsoring organisations for consideration in preparation of Recommendation 5 (see below). ix Looking out from the middle

11 STAKEHOLDER PARTICIPATION Recommendation 2 Organisations should clearly and actively communicate their roles and responsibilities to service users and carers involved in their work and also in the wider community so there is clear understanding of what they do. Themes: Communication, Values, Knowledge of organisations Proposed actions for development How organisations communicate with the public was felt to be very important in developing user involvement and in emphasising the importance of relationship and trust building as part of this. The evidence from the interviews clearly shows a lack of knowledge among the groups consulted about the three commissioning organisations. One way of helping with this could be for NISCC, RQIA and SCIE to consider how key staff members involved in participation work can spend dedicated time working with user groups in the community. This experience would be valuable in helping facilitate the participation of isolated/hard-to-reach groups. Providing such opportunities would also send a positive message to groups that organisations are committed to proactively seeking out seldom-heard groups. The database could be used as the basis for generating contacts with groups in the community. This is something that a participation group across all three organisations could help coordinate. In terms of communicating with the public, the three sponsoring organisations could also work together to organise an annual information event to publicise their work in Northern Ireland and also highlight their interest in engaging and involving the user perspective in their work. Contacts from the database of service user/carer groups could again be used to attract a wide variety of groups to such an event. Recommendation 3 Organisations seeking user involvement should commit themselves to an agreed set of principles/values that have been developed along with service users and carers. Theme: Values Proposed actions for development The consultation stressed the importance of human and professional values such as respect, rights, humanity, individuality and partnership working as being central to working effectively with user interests. The three organisations could work together on agreeing a set of principles/values to guide their work on user involvement in Northern Ireland. This could be developed as a preliminary project by the participation group. x

12 To ensure their practices consistently reflect such a value base, the sponsoring organisations should evaluate the experience of involvement from the perspective of both the user and staff members involved. Good practice in this area currently exists in both the Northern Health and Social Services Board (NHSSB) and the Eastern Health and Social Services Board (EHSSB) in Northern Ireland where checklists are completed to accompany each activity that has involved a user perspective. The three organisations should work together with service user representatives to develop an assessment/evaluative tool that could be used in each of their respective working environments. This would further reinforce the views expressed consistently by groups about their rights to participation and would also ensure that user involvement is perceived as a process instead of a series of one-off events. Recommendation 4 Staff within each commissioning organisation should attend training on service user involvement. This should be commissioned from user-led groups and should also be available for service users and carers who feel that they would benefit from this. Theme: Training Proposed actions for development Training in the area of user involvement should be compulsory for all staff in organisations who are actively engaged in participation work (training for staff in user involvement issues currently occurs in both SCIE and NISCC). Such training can be delivered in partnership with experienced user-led organisations. Staff induction is also an opportunity for ensuring that new staff understand the agencies commitment to participation. Training should also be offered to service users and carers as a form of support and capacity building. The three commissioning organisations could work together to share the contacts they have with user organisations when organising training. Another way for the commissioning organisations to work together is by offering mentoring for new participation workers from more experienced staff members across the three agencies. This would be a further method of promoting closer interagency working in this area. Recommendation 5 The chief executive of each commissioning organisation should report annually to their board about their progress in involving service users and the resources needed to develop this work in the next financial year. Theme: Practicalities xi Looking out from the middle

13 STAKEHOLDER PARTICIPATION Proposed actions for development Organisations must continually consider and monitor the practical supports required as part of facilitating effective user involvement. To assist in this process, the three sponsoring organisations should use this report to consider ways of building practical supports for user involvement. Recommendation 6 The findings from this small-scale study support the establishment of a network for user groups in Northern Ireland as one way in which such organisations can work together to build their capacity. Theme: Support for a user group network Proposed actions for development There are a number of issues which need to be considered, in particular issues of funding and ownership of such a network and avoiding any duplication with other similar initiatives. (The Draft framework for stakeholder involvement in health and social care [DHSSPSNI, 2007a] describes current plans by Northern Ireland s Department of Health, Social Services and Public Safety [DHSSPSNI] to set up a stakeholder involvement regional network whose function would be to provide a platform for influencing strategic priorities and decision making in health and social care services across Northern Ireland.) The setting up of the participation group could act as an interim way in which the three organisations could work together to take forward the user participation agenda. Recommendation 7 A designated person should be appointed in each of the three commissioning organisations to ensure the participation of service users in all aspects of their work. Theme: Resources Proposed actions for development This person should be appointed at senior level with a specified and adequate budget and have an input at a strategic level in the organisation as a way of ensuring user involvement activities are reported on and evaluated. Such participation managers in each of the three organisations should examine ways in which their resources could be combined and information shared. (SCIE already employ a principal advisor in participation and RQIA a public participation manager. In NISCC, the director of corporate services has responsibility for facilitating the Council s users and carers reference groups.) xii

14 Recommendation 8 Service users and carers should be given feedback about the outcomes of any consultation they have been involved in. Theme: Feedback and outcomes Proposed actions for development This is already established practice in many of Northern Ireland s HSSBs where feedback is monitored and audited through an established checklist covering this and other aspects of involvement. The three organisations should work together in agreeing best practice and protocols around giving feedback to users following participation and also about ensuring that people are properly informed in an appropriate manner about the outcomes emerging from their participation. The three organisations should make this available electronically on their websites. xiii Looking out from the middle

15 stakeholder participation 1 Introduction The three organisations sponsoring this consultation (NISCC, RQIA and SCIE), hereafter referred to as the commissioning organisations, were keen to ensure effective participation of users and carers in their work. To build on the progress they had already achieved, they were particularly interested in examining how service user and carer involvement might benefit from having a broader and more multiagency perspective. To investigate this further, a consultation focusing on user involvement was commissioned by SCIE on behalf of these three organisations in October The commissioning organisations Northern Ireland Social Care Council (NISCC) NISCC was set up by the government to raise standards across the Northern Ireland social care workforce. It aims to achieve this objective by ensuring that all those people working in social work and social care and providing services to people in need are registered and work to high standards of quality. Regulation and Quality Improvement Authority (RQIA) RQIA is an independent organisation that is responsible for monitoring and inspecting both the availability and quality of health and social care services in Northern Ireland, and encouraging improvements in the quality of those services. Social Care Institute for Excellence (SCIE) SCIE was also established by the government to improve social care services for adults and children in the United Kingdom. It aims to achieve this by identifying good practice and helping to ensure such practice becomes a part of everyday social care for people both receiving and providing services. 1.2 Aims of the consultation This consultation had four aims: 1. To provide a short summary of the history and principles of user involvement. 2. To describe the current situation in Northern Ireland. 3. To discuss a range of options for the further inclusion and participation of users in the work of NISCC, RQIA and SCIE. 4. To make recommendations to inform the development of a future strategy for user involvement at a strategic level in Northern Ireland. In addition the following objectives were also included:. To identify the number of service user organisations in Northern Ireland. 2. To explore and investigate the options for involving and improving service user involvement in Northern Ireland social care and health services at a strategic level. 3. To undertake the work in partnership with users.

16 4. To acknowledge and recommend options as to how social care agencies need for service user involvement can be most effectively and efficiently delivered, while recognising the importance of the aspirations of users to develop and maintain their own autonomous voices. 5. To ensure that all relevant stakeholder groups are consulted including representatives of already existing user forums, individual users, individual carers, carers organisations, senior managers, practitioners, social care educators and representatives of voluntary and statutory sectors. 6. To make recommendations regarding the development of a user/carer involvement strategy to be progressed by the three organisations and used to obtain the views of users and carers about the quality of care in relation to services purchased or provided on their behalf. In response, this consultation was awarded to and completed by a project team from Northern Ireland involving service users, carers, agency representatives and academic staff from Queen s University, Belfast. Partnership working formed the basis of how this work was undertaken from beginning to end. Care has been taken to ensure the report is written in a way that is understandable and accessible for everybody involved in the consultation and for the wider community who will have an interest in this work. 2 Looking out from the middle

17 stakeholder participation 2 Methodology: how the consultation was carried out 2.1 Introduction There are a variety of ways in which such consultations can take place. First, the team decided that we needed to produce both qualitative (information which expresses thoughts and ideas) and quantitative (information expressed through numbers) information. This meant ensuring that the interview was designed in a way that would allow such information to be expressed. Although there were some limitations to this approach, one of its strengths is that it helped us piece together a fairly reliable account of the views of the people who were involved in the consultation. This also enabled us to draw conclusions that reflected these opinions. The processes that we went through in order to do this work in many ways reflect the level of thought, preparation and sensitivity required when undertaking user involvement projects. However, giving attention to detail and preparation has resulted in a project that service users, carers and project team members have all seriously and genuinely committed to. This section of the report takes the reader through the stages involved in undertaking the consultation. 2.2 Managing the project A steering group was established at the beginning of the project with membership from three service user/carer organisations and the project leader. This group met twice during the life of the work. The project leader and project team members also met with the commissioners reference group on two occasions to report on the project. The project leader provided regular reports for these meetings. The project team consisted of service user/carer representatives and academic staff. This group met on a total of four occasions over the project and managed all the ongoing aspects of the consultation. 2.3 Reviewing the literature The work was set in a broader context by providing a brief narrative review of the literature about the principles and history of user involvement. This review informed the selection of the sample, the content and design of the interview schedule and the identification of themes used in the analysis of materials. In addition, themes that emerged from the literature also supported the report s recommendations. 2.4 Designing a sample frame for the consultation The original guidance provided by SCIE on behalf of the three organisations stated that a variety of individuals, groups and stakeholders from across the health and social care spectrum in Northern Ireland needed to be consulted in this work. In developing this further, the sponsoring organisations indicated that 26 such 3

18 consultations should take place. Stress was placed on the importance of hearing from service users and carers on the ground in terms of what works from their experiences of public bodies engaging successfully with users. What was very clear and motivating from the outset was that the three organisations supporting the consultation were genuinely keen to find out how to make user involvement work. Mapping the extent of user involvement across Northern Ireland (project aim 2, see page 1) was a significant task, but nonetheless crucial in terms of helping the team identify who should be involved in the consultation. Two service user teams and the project leader completed this aspect of the work. A detailed preliminary database of service user and community organisations was constructed by: contacting district councils in each HSSB area in Northern Ireland telephone and contact with relevant staff, including trust and board chief executives, equality managers and community development managers in the board areas with responsibility for user involvement initiatives internet research to identify groups through organisations web-based directories/ databases inquiries through a Voluntary Organisations Forum (VOF) existing knowledge/networks from within the project team. In this way, the team was able to produce a detailed sample frame (the total list of organisations from which a smaller number are selected for involvement in the consultation) from which 26 groups would be selected for the consultation. 2.5 selecting the sample The following criteria were then applied in relation to the selection of these groups: balanced representation of service user and carer interests the need for user-led, user-facilitated and representational groups inclusion of both health and social care aspects inclusion of minority ethnic perspectives representation of voluntary and statutory sector interests representation of hard-to-reach/seldom-heard groups representation of a range of service user experiences, that is, physical disability, learning disability, mental health, children, older people, criminal justice consideration to the 1998 Northern Ireland Act (Section 75) inclusion of identified groupings and categories in terms of equality inclusion of both urban and rural perspectives. The team then selected 26 groups that together represented all of these factors (see Appendix 2). At the request of RQIA, we also agreed to survey the views of the three organisations commissioning the project, two private residential homes for older people and a relatives group. In addition, we interviewed three individuals from senior management, community development and health backgrounds, all of whom were active in promoting user involvement initiatives. 4 Looking out from the middle

19 stakeholder participation The total number of individuals who would therefore be involved in the 35 consultations was 148 (n=148, where n = the letter used in research to refer to number). 2.6 Ethical approval The Social Research Ethics Committee (SREC) of the School of Sociology, Social Policy and Social Work, Queen s University, Belfast granted ethical approval for the consultation. However, the project leader advised the commissioners reference group that this approval did not extend to consulting with individual service users and carers, which was a requirement in the original project instructions. We therefore agreed that the consultations would only take place with established groups. 2.7 Designing the interview As this consultation would involve inquiry into people s thoughts, ideas and experiences on user involvement, the team felt that the best way of gathering this information would be through an interview containing a mixture of questions that would permit groups to openly express their views on the subject. It was also felt important, however, to include other types of focused questions that seemed to be important in the context of the existing research and policy literature that we examined. This helped us further explore views, thoughts and feelings about key issues identified with the aims of the project. The type of interview developed was called a semi-structured interview. By its very nature, such an interview had to include open questions, where respondents could answer questions freely in their own words, and closed questions, where people had to choose from fixed options. Another feature of this interview was its inclusion of prompts after each question which were used to help respondents better understand a question if they had any difficulties. Two service user teams and the project leader constructed the interview schedule (the term used to describe all of the questions in an interview and their instructions) (see Appendix 3). When the questions were agreed, these were then shared with other project team members to ensure they were accessible and easily understood given that a diversity of groups would be completing them. This also acted as a way of piloting (testing) the interview in terms of its suitability for accessing the information we were interested in. In addition to the interview which was designed to be easily understood, it also had to include questions directly relevant to the aims of the consultation. The interview had questions around skills necessary in the process of user involvement from both the user and host organisation s perspectives. In this way, again, the literature evidence had an important influence in the design of the interview. 2.8 Preparation for the interviews The discussion in the literature around the history and principles of user involvement recognised that consultation fatigue was an issue that was very real for many groups. The project leader, therefore, made personal contact by telephone with all 26 groups identified for the sample to explain in detail what this consultation was about. In 5

20 some instances this contact was preceded by contact with a third party worker who was linked to a group. This was felt to be more sensitive than a telephone call coming from the project leader out of the blue. In this way, people had a chance to ask about the consultation and furthermore consult with other members of their organisation/group before committing themselves to participating. To help the groups in this process, relevant background information on the project (participant information form, see Appendix 4) was sent by . Once group representatives contacted the project leader with a decision to be involved or not, which in some instances took a few weeks, a copy of the interview schedule and consent form (Appendix 3) were then forwarded. For some of the organisations consulted, this was their first experience of such involvement, so these sensitive preparations were necessary to ensure such people would not be deterred from being involved in similar future initiatives. Project team members were then provided with a list of contact details for the organisations that had agreed to participate. Only one group did not take part in the consultation, meaning there was a total of 25 groups involved in this part of the work (n=25). 2.9 Conducting the interviews The majority of the interviews took place face-to-face with the groups. When this was not possible, in a small number of cases groups sent through their completed interviews by or post. As discussed above, the interview schedules were sent out in advance in order to facilitate plenty of time for consideration of responses to the questions. Eight of the project team members were asked to complete several interviews each and to summarise the responses of the groups to the questions. The interviews tended to be very challenging for both the interviewers and the groups given the complexity and sensitivity of the subject matter being discussed. In most cases these lasted on average two hours each. The roles of the three organisations (NISCC, RQIA and SCIE) had to be explained in most instances, which was crucial in terms of allowing the groups to be informed enough to make their views heard; it also helped in the process of establishing trust. As said earlier, this was the first experience of involvement for some groups in a consultation like this, so flexibility and skills were needed on the part of the interviewer. When the interviews were finished, each interviewer then completed a summary using a structure that had been designed by a service user project team member. This would assist with analysing the findings Scoping user involvement: the current situation in Northern Ireland As previously mentioned, the approach to determining the nature of service user involvement in Northern Ireland was through making contact with the chief executives of the 19 Health and Social Services Trusts (HSSTs) in Northern Ireland. In 6 Looking out from the middle

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